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Comparative Analysis of Recommendations for Timingand Frequency of Home Blood Pressure Monitoring in Clinical Practice Guidelines
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摘要:
目的 对比分析临床实践指南中家庭血压监测(home blood pressure monitoring，HBPM)时间和频率的推荐意见，以帮助临床医生遴选最佳推荐意见，同时为未来指南推荐意见的形成提供建议。 方法 系统检索和筛选近5年发表的高血压相关临床实践指南，提取HBPM时间和频率的推荐意见进行统计分析。 结果 共纳入包含HBPM时间和/或频率相关推荐意见的指南21篇，分别由16个国家或地区的机构制定。对于HBPM时间，所有指南均推荐每天进行早晚两次血压测量，早上血压测量时间为服用降压药前(94.4%，17/18)、早餐前(72.2%，13/18)和排尿后(55.6%，10/18)，晚上血压测量时间为晚餐前(50.0%，8/16)、睡前(37.5%，6/16)和晚餐后2 h(6.3%，1/16)。对于HBPM频率，9篇(40.9%，9/22)指南建议就诊前1周至少连续测量3 d，其他指南则建议至少连续测量4 d(18.2%，4/22)、5 d(13.6%，3/22)或7 d(27.3%，6/22)。 结论 不同国家和地区的指南关于HBPM时间和频率的推荐意见存在较大差异，建议未来在形成推荐意见时应全面检索、评价和综合证据，充分考虑利弊平衡、可行性、患者偏好与价值观等因素，同时结合指南的实施环境，形成最佳推荐意见。 Abstract:Objective To compare and analyze the recommendations for the timing and frequency of home blood pressure monitoring (HBPM) in clinical practice guidelines to help clinicians select the best recommendations and provide suggestions for the development of recommendations in the future. Methods Clinical practice guidelines related to hypertension published in the last five years were systematically searched and screened, and the recommendations for the timing and frequency of HBPM were extracted for statistical analysis. Results A total of 21 guidelines developed by institutions in 16 countries or regions were included, containing recommendations related to the timing and/or frequency of HBPM. For the HBPM timing, all guidelines recommend that blood pressure measurements be taken twice a day, in the morning and evening. In the morning blood pressure should be measured before taking antihypertensive medication (94.4%, 17/18), before breakfast (72.2%, 13/18) and after urination (55.6%, 10/18), while in the evening it should be taken before dinner (50.0%, 8/16), before bedtime (37.5%, 6/16) or 2 hours after dinner (6.3%, 1/16).For HBPM frequency, 9 (40.9%, 9/22) guidelines recommend at least 3 consecutive days of measurement in the week before the visit, and others suggest that measurements should be taken consecutively for at least 4 d (18.2%, 4/22), 5 d (13.6%, 3/22) or 7 d (27.3%, 6/22) days. Conclusions The guidelines of different countries and regions have great differences in recommendations on the timing and frequency of HBPM. It is recommended that future guideline developers develop the best recommendations after a thorough search, evaluation, and synthesis of the evidence, with full consideration of the balance of pros and cons, feasibility, patient preferences and values, as well as the context in which the guidelines are implemented. -
Key words:
- hypertension guidelines /
- home blood pressure monitoring /
- recommendations
作者贡献：刘云兰、任梦娟、王子君、苏仁凤负责文献筛选和信息提取；刘云兰负责统计数据并撰写论文；任梦娟、王子君、苏仁凤、罗旭飞、郭强强、余静、邢爱君、周晓阳负责初稿修改；陈耀龙负责论文审校。利益冲突：所有作者均声明不存在利益冲突 -
表 1 纳入指南的基本特征
编号 国家/地区 发表年份 制订机构 指南类型 指南版本 是否报告资助 是否报告利益冲突 证据质量分级方法 推荐强度分级方法 是否报告系统检索证据 是否考虑患者意愿 基于的证据类型 1[13] 新加坡 2017 新加坡卫生部 综合* 原版 否 否 SIGN Modified SIGN 是 否 指南 2[14] 亚洲 2018 HOPE亚洲网络 监测 原版 是 是 ESC ESC 是 是 指南，队列研究 3[15] 巴基斯坦 2018 巴基斯坦高血压联盟 综合* 更新版 否 否 否 否 否 否 指南 4[16] 马来西亚 2018 马来西亚高血压学会等 管理 更新版 是 是 USPSTF Modified SIGN 是 否 指南 5[17] 欧洲 2018 欧洲心脏病学会等 管理 更新版 是 是 ESC ESC 是 否 指南 6[18] 美国 2019 美国心脏协会 监测 更新版 否 是 否 否 否 否 指南，横断面研究 7[19] 泰国 2019 泰国高血压学会 治疗 原版 否 否 ESC ESC 否 否 无 8[20] 中国 2019 中国高血压联盟 监测 更新版 否 否 否 否 否 否 指南，横断面研究 9[21] 中国 2019 中华医学会 诊疗 原版 否 是 否 否 否 否 指南 10[22] 中国 2019 中国老年医学学会高血压分会等 管理 原版 否 是 ESC ESC 是 否 指南 11[23] 中国 2019 中国高血压联盟 防治 更新版 是 是 ESC ESC 是 否 指南 12[24] 日本 2019 日本高血压学会 管理 更新版 否 是 GRADE GRADE 是 否 指南 13[25] 韩国 2019 韩国高血压学会 管理 更新版 否 是 ESC ESC 是 否 指南 14[26] 波兰 2019 波兰高血压学会 管理 更新版 否 否 否 自定义# 是 否 无 15[27] 国际 2020 国际高血压学会 综合* 原版 否 是 否 否 否 否 指南 16[28] 加拿大 2020 加拿大高血压学会 综合* 更新版 是 是 否 自定义# 是 否 无 17[29] 印度 2020 印度医师协会等 综合* 更新版 否 否 否 否 否 否 无 18[30] 牙买加 2020 牙买加卫生福利部 管理 更新版 否 否 否 否 否 否 无 19[31] 中国台湾 2020 台湾高血压学会等 监测 原版 否 是 ESC ESC 是 否 横断面研究，队列研究 20[32] 拉丁美洲 2020 拉丁美洲高血压学会 监测 原版 否 是 否 否 否 否 指南 21[33] 欧洲 2021 欧洲高血压学会 监测 原版 否 是 否 否 否 否 指南 *无法根据指南标题判断其类型，但内容包括预防、诊断、治疗、管理等3种类型及以上；#仅报告分级标准，无具体分级方法名称；HOPE亚洲网络：亚洲高血压、脑、心血管和肾脏结果预防和证据网络；SIGN：苏格兰校际指南网络；GRADE：推荐分级的评估、制订与评价；USPSTF：美国预防服务工作组；ESC：欧洲心脏病学会 
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表 2 家庭血压监测时间推荐意见对比分析
国家/地区 发表年份 早上测量时间(n=18) 晚上测量时间(n=16) 测量前30 min准备(n=13) 醒后1 h内 服药前 早餐前 排尿后 服药前 晚餐前 晚餐后2 h 睡前 洗澡前 避免剧烈运动 避免摄入咖啡 避免吸烟 避免饮酒 亚洲 2018 √(1B) √(1B) √(1B) √(1B) √(1B) √(1B) √(1B) √(1B) 巴基斯坦 2018 √ √ 马来西亚 2018 √ √ √ √ √ √ 美国 2019 √ √ √ 泰国 2019 √(1B) √(1B) √(1B) √(1B) 中国(1) 2019 √ √ √ √ √ √ 中国(2) 2019 √ √ √ 中国(3) 2019 √ √ √ 日本 2019 √ √ √ √ √(或) √(或) √ √ √ √ 韩国 2019 √ √ √ √ √ √ √ √ 波兰 2019 √ √ √ √ √ √ 国际 2020 √ √ √ √ √ √ 加拿大 2020 √ √ √ √ √† √† √† 印度 2020 √ √ √ √ √ √ 牙买加 2020 √ √ √ √ √ 中国台湾 2020 √(1B) √(1B) √(1B) √(1B) √(1B)‡ √ √ 拉丁美洲 2020 √ √ √* √* 欧洲 2021 √ √ √ √ √ √ √ 推荐指南数量[n(%)] 5 (27.8) 17(94.4) 13(72.2) 10(55.6) 4(25.0) 8(50.0) 1(6.3) 6(37.5) 2(12.5) 9(69.2) 11(84.6) 11(84.6) 4(30.8) 同一指南在同一主题下标注“√”的推荐意见应同时满足，标注“或”的推荐意见表示两者选择其一；中国(1)：《2019中国家庭血压监测指南》；中国(2)：《高血压基层诊疗指南(2019年)》；中国(3)：《中国高血压防治指南(2018年修订版)》；√：表示指南中提及相关推荐；1B：根据ESC分级系统对证据质量和推荐强度分级的结果，1表示推荐强度为“推荐”(证据和/或专家一致认为该治疗或方法有益、有用或有效)，B表示证据等级为“B级”(证据来源于随机对照试验或大样本非随机对照研究)；†测量血压前1 h；‡ 睡前1 h; *测量血压前
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表 3 家庭血压监测频率推荐意见对比分析
国家/地区 发表年份 测量天数(诊断及血压控制不良的管理)(n=22) 测量天数(血压控制良好的管理)(n=8) 每天测量次数(n=21) 每次测量的读数次数(n=21) 3~7 d 4~7 d 5~7 d 7 d 每周至少1 d 每周1~2 d 每周或每月1~2 d 每3个月4~7 d 2次(早上和晚上) 连续读数2次 至少连续读数2次 连续读数2~3次 连续读数1~3次 新加坡 2017 √ √ √ 亚洲 2018 √(1B) √(1B) √(1B) 欧洲 2018 √ √ √ 巴基斯坦 2018 √ √ √ 马来西亚 2018 √ √ √ 美国 2019 √ √ √ 泰国 2019 √(1B) √(1B) √(1B) 中国(1) 2019 √ √ √ √ 中国(2) 2019 √ √ √ √ 中国(3) 2019 √ √ √ √ 中国(4) 2019 √ √* √ √ 日本 2019 √ √ √ 韩国 2019 √(管理) √(诊断) √ √ 波兰 2019 √ √ √ 国际 2020 √ √ √ √ 加拿大 2020 √ √ √ √ 印度 2020 √ √ √ 牙买加 2020 √ √ √ 中国台湾 2020 √(1B) √(或，1B) √(或，1B) √(1B) √(1B) 拉丁美洲 2020 √ √ √ 欧洲 2021 √ √ √ √ 推荐指南数量[n(%)] 9
(40.9)4
(18.2)3
(13.6)6
(27.3)2
(25.0)3
(37.5)2
(25.0)2
(25.0)21
(100.0)13
(61.9)3
(14.3)4
(19.0)1
(4.8)同一指南在同一主题下标注“√”的推荐意见应同时满足，标注“或”的推荐意见表示两者选择其一；中国(1)、中国(2)、中国(3)：同表 2；中国(4)：《中国老年高血压管理指南2019》；√：同表 2；1B：同表 2；*每周仅测1 d血压
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表 4 家庭血压监测频率相关原始研究分析
指南 原始研究证据 国家/地区 发表年份 推荐意见 研究类型 发表年份 结局指标 效应量 主要结论 亚洲 2018 1周3~7 d 队列研究[34] 2011 心血管事件预测 SBP: 3 d HR=1.017；7 d HR=1.021
DBP: 3 d HR=1.028；7 d HR=1.034至少测量3 d 随访研究[35] 2004 卒中预测 SBP: 3 d HR=20%；14 d HR=31%
DBP: 3 d HR=12%；14 d HR=21%最好测量14 d 美国 2019 1周3~7 d 横断面研究[36] 1997 与ABPM的相关性 SBP: 3 d r=0.68；6 d RH=0.71
DBP: 3 d r=0.75；6 d RH=0.79至少测量3 d 横断面研究[37] 2010 心血管事件预测 SBP: 1 d HR=1.029；3 d HR=1.032
SBP: 1 d HR=1.034；3 d HR=1.037最好测量3 d 中国 2019 1周5~7 d 横断面研究[38] 2010 3 d和6 d家庭血压值的相关性 SBP: 早上r=0.97；晚上r=0.98
DBP: 早上r=0.98；晚上r=0.97至少测量3 d 中国台湾 2020 1周4~7 d 队列研究[34] 2011 心血管事件预测 SBP: 3 d HR=1.017；7 d HR=1.021
DBP: 3 d HR=1.028；7 d HR=1.034至少测量3 d 队列研究[39] 2018 心血管事件预测 SBP: 3 d HR=1.019；7 d HR=1.021
DBP: 3 d HR=1.038；7 d HR=1.045至少测量3 d 横断面研究[40] 2018 第1周和第2周家庭血压值的一致性 SBP: 3 d ICC=0.91；7 d ICC=0.94
DBP: 3 d ICC=0.88；7 d ICC=0.93至少测量3 d SBP：收缩压；DBP：舒张压；ABPM：动态血压监测；HR：风险比；RH: 相对风险；r：相关系数; ICC: 组内相关系数
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